FAILINGS were highlighted at a Weymouth care home after a 90-year-old man fell and later died, a coroner has ruled.

William Edward Armstrong died shortly after falling at Agincourt Care Home in Weymouth on February 18, 2012.

Speaking at an inquest at County Hall in Dorchester, assistant coroner for Dorset Richard Middleton found there had been failings at the care home but he added that the death of Mr Armstrong was not a result of negligence.

Mr Armstrong, known as ‘Billy’, was found by a care worker in the early hours of the morning collapsed at the bottom of a fire exit stairwell.

The coroner issued a narrative verdict. He suggested Mr Armstrong had left his room through his patio door undetected between 5.30am and 6.45am.

He said an inadequate warning system failed to alert staff which allowed Mr Armstrong to wander to a nearby stairwell and open a fire exit door that should have been locked.

The coroner suggested Mr Armstrong then either slipped or fell, hitting his head in the process. He was taken to Dorset County Hospital and died later that evening.

Pathologist Dr Mark Deverill, speaking as a witness, recorded Mr Armstrong’s death as natural. He said he suffered from pulmonary edema and bronchial pneumonia.

The coroner agreed with this statement but suggested on the evidence heard hypothermia was also a contributing factor.

Prior to the incident, Mr Armstrong had been living with Alzheimer’s and suffered from dementia. He was transferred to Agincourt Care Home on January 6. He had previously been cared for by his wife, Ruth.

The court heard only two members of staff were on duty the evening of the incident, providing two-hourly checks on residents. It was during these checks at 5.30am and 6.45am Mr Armstrong went missing.

Barrister Matthew Barnes, representing Mr Armstrong’s family, said there were failures that led to an absence of care.

He said Mrs Armstrong had provided the home with details of Mr Armstrong’s habits, including occasions where he had wandered.

The court also heard how the care home’s deputy manager at the time, Jo Tames, had agreed to provide an alarm mat for her husband, which never materialised. Mr Barnes submitted the home had failed to properly identify the risks and needs of Mr Armstrong, as well as secure doors leading from his bedroom and fire exit. The court heard outside perimeter checks had been conducted on all doors on the evening of February 17 but patio doors could still be opened by residents on the inside.

In her evidence, Mrs Tames confirmed all doors should have been locked on the outside but she was aware of a resident in the past using the fire exit for smoking purposes. No action had been taken to stop this, the court heard.

Tom Banks, representing Agincourt Care Home, said a gross failure would have to have occurred for neglect to be considered.

He added: “There needs to be a failure which is tantamount to an absence of the provision of necessary care.”

A statement from Agincourt Care Home read: “Resident safety when dealing with increasingly vulnerable adults is a paramount concern and we work with all involved to manage this, whilst respecting individual rights, freedom and choice. Our thoughts remain with the family and we are very sorry for their loss.”

A statement from the family read: “We trust that those involved in providing care to Billy will take the opportunity to learn from the failings identified in the provision of that care during the course of the inquest. A civil claim is ongoing.”

The current manager of Agincourt Care Home has revealed lessons have been learned from the incident.

Giving evidence during the two-day inquest, Matthew Dennis-Andrews said they now had an improved call bell system throughout the home.

He added that a door alarm system had also been installed after a recommendation from Environmental Health.

Patio doors can still be opened from the inside by residents but an alert will sound if they are opened. A new pin alarm has also been added to the fire exit door.

Mr Dennis-Andrews said he was not in favour of locking the patio doors from the inside.

He said: “We are not a prison. We are a care home. We are their home.”